Question;

What is maternal health?,  maternal health care services (Antenatal-, postpartum care)?

Continuum of care

What is maternal mortality? Maternal mortality worldwide?

MDGs and SDGs in relation to maternal mortality in the world

The leading causes of maternal deaths in the world?

Country context: Ethiopia ( Description of the country, maternal mortality rate in Ethiopia, The healthcare system, How much of GDP invested in Healthcare, Private/ public health care.  Mortality rate in the country, leading causes of maternal deaths in the country) Any relevant data

Answer;

Introduction

Maternal health refers to health status of women during the pregnancy period, childbirth and during the post-delivery period (1). The health care services provided to the pregnant women before child delivery are referred to as antenatal care while the services provided to the mother and after delivery are referred to as the postnatal health care services (1). This paper describes the aspects of maternal health, the global mortality rates, leading causes of mortality rates and also provides a detailed description of the maternal health status in Ethiopia.

Prenatal and postnatal care

Prenatal care comprises of trainings and treatments provided to promote a healthy pregnancy, labor and child delivery. Any complications or issues with pregnancy are identified during prenatal visits. Lack of proper prenatal care may increase the chances of low birth weight and infant mortality (2). Prenatal care should begin at least three months before the attempt to conceive. During that time, the expectant woman is expected to avoiding drinking alcohol or cigarette smoking, take iron supplements, avoid occupational and home hazards among other practices that promotes maternal and fetal health. Postnatal care begins as soon as a baby is born and continues to a period of up to six or eight weeks. During the post delivery period, the new mother goes through many emotional and physical changes as they learn to take care of the newborn. Postnatal care involves encouraging the new mother to get adequate rest, eat a healthy diet, and maintain high level of hygiene in the genital area to prevent occurrence of infections (2).

Continuum of Care

The continuum of care is considered to be a core principle of promoting newborn and maternal health as a strategy to reduce the rate of neonatal and maternal deaths. The continuum of care was emphasized in the Lancet Neonatal Survival Series and the World Health Report of 2005.The continuum of care also facilitated for the foundation of the Opportunities for Africa’s Newborns (3). The continuum of care is also emphasized upon in the Millennium Development Goals (MDG) 4 and 5.The main aim for MDG 4 and 5 was to significantly reduce the maternal mortality rates by three quarters between 1990 and 2015.The continuum of care for the neonatal , child and maternal health is facilitated by the access to the health care provided by outreach, outpatient  and clinical services to families and the community throughout the pregnancy, child birth, post-natal and childhood periods. Saving maternal life depends on the quality of health care services provided throughout the care continuum (3).

The continuum of care facilitates for good maternal health in wealthy countries particularly those that implement government-funded systems of health care and near-universal health care coverage. Countries that are ranked best in maintaining good maternal health have effective continuum of care for the neonates, mothers and children in terms of both policy and practice. However, majority of the low-income countries with limited financial and human resources as well as inadequate healthcare infrastructure, face challenges in the implementation of the continuum of care. However, they make efforts to reduce the neonatal, child and maternal mortality by introducing health care close to families (3).

Global Maternal Mortality

According to the World Health Organization (WHO), maternal mortality refers to the death of a pregnant woman or death of a woman within 42 days following the termination of a pregnancy regardless of the site or duration of pregnancy from causes related to aggravation by the pregnancy or management of the pregnancy rather than incidental or accidental causes (4). According to WHO ,approximately 810 maternal deaths occurred in 2017 due to preventable causes related to childbirth and pregnancy. It was reported that the ratio of maternal mortality reduced by approximately 38% between 2000 and 2017 worldwide. Approximately 94% of the total maternal deaths were recorded in middle and low-income countries. Southern Asia accounted for approximately one fifth of the maternal deaths while Sub-Saharan Africa accounted for approximately two thirds of the maternal deaths(5). Quality health care before, during and after child delivery can prevent the neonate ,infant and maternal mortality. As at 2017, the Fragile States Index revealed that 15 countries, were ranked as high alert in terms of high maternal mortalities. They included Ethiopia, Yemen, Somalia, South Sudan and Nigeria among others. Some of the factors associated with the high maternal mortality rates include excessive bleeding and infections after childbirth ,hypertension issues such as eclampsia and pre-eclampsia, unsafe abortion and complications that result from child delivery (4,5).

Maternal Health in the Context of Ethiopia

Ethiopia is located in Eastern Africa and is ranked as one of the most populous countries in Africa after Nigeria. According to the Ethiopian demographic and Health Survey of 2016, approximately 62% of the Ethiopian women had access to antenatal care,17% accessed post-natal care,28% gave birth under skilled attendance while 35% of the women used contraceptive methods across the country (6). In 2003, the Ethiopian government introduced the health service extension program (HSEP) with an aim of increasing the accessibility of health care to majority of the Ethiopian population and enhance equity in the health care services delivered to the community. The main components of the program were disease prevention and control, family health, environmental sanitization and hygiene as well as health communication and education. Under the family health services, the program focuses on family planning, nutrition, reproductive health and immunization (6). However, according to Ethiopia health (2012) ,the Ethiopian women failed to use the health care services due to several reasons. The country lacked an effective health insurance plan and the citizens had to access their health care services through out of the pocket approach. Access to health in the rural areas of Ethiopia was also difficult yet it was approximated that 76% of the women lived in the rural areas. Lack of good transport infrastructure, inadequate means of transport, and long distances between health care facilities were the leading barriers to accessing quality health care services. Among the few accessible health care facilities, there were shortages of human resources and some of the drugs required (6).

According to the USAID, Ethiopia is considered to be among countries with the highest maternal mortality rates globally. Approximately 120,000 babies die during neonatal stage. More than 40% of under-five mortalities in the country are neonatal deaths (1). The USAID partners with the Ethiopian government to reduce neonatal, child and maternal mortality rates through evidence-based interventions and integrated care packages through out the continuum of care at facility, family and community levels. They contribute to increased accessibility of health care services such as newborn care and birth attendance (1). According to WHO Africa the country initiated the National Health Care Quality Strategy (2016-2020) in 2019 that placed the newborn, child and maternal health as a priority with an aim of reducing maternal mortality and still births. It aimed at reducing the ratio of maternal mortality to less than 199 in every 100,000 births by year 2020, decrease the rate of neonatal mortality to less than 10 per every 1000 live births and reduce the rate of still births to less than 10 in every 1000 births (4).

 

As at 2014, the World bank indicators of development showed that the total percentage expenditure on the healthcare sector was approximately 78.15%. The country’s health expenditure share was approximately 4% (7). The  healthcare GDP share had fluctuated significantly over the recent years and had demonstrated a decreasing trend from 2002 to 2016 (8). The primary health care system of Ethiopia receives funding from external partners. For instance, the external funding has increased from six million USD in 1995 to approximately 883 million dollars in 2014 (6). The leading causes of maternal mortality in Ethiopia, 46.5% are due to postpartum hemorrhage, hypertensive disorders (16% ),abortion (9.3%),puerperal sepsis (7%),obstructed labor (2.3%) and antepartum hemorrhage (2.3%). Regarding the location of maternal deaths, the largest mortality rate occurs at home (56%), 33% in health facilities and 9% occur in other places (9).

The Maternal and Newborn Health in Ethiopia ( MaNHEP) initiated an innovative technology with an aim of reducing newborn and mortality rates by training family and community members on how to provide first aid services that can potentially reduce the mortality rates during child delivery (10). The project’s goal is to enhance the quality of  maternity health care. In effort to achieve its goals, the project has strengthened links between the communities and the health care providers in order to enhance tracking of births and pregnancies as well as establish reliable referrals for the management of complications. It also aims at ensuring that the public health care providers visit the mothers and their newborns preferably within 48 hours after child delivery (10).

In 2015, interventions to reduce the maternal mortality rates to less than 267 deaths per 100,000 live births were under implementation. The interventions included postnatal care, antenatal care and services related with skilled birth attendance. Pregnant women received insecticidal-treated nets, tetanus vaccination and nutrition interventions such as micronutrient supplementation (11). All pregnant women were encouraged to seek child delivery services in healthcare facilities. Maternal deaths can be prevented through provision of quality prenatal and postnatal health care services by skilled health care providers. Excessive bleeding after childbirth can be controlled and managed by injecting oxytocic to the mother immediately after delivering the child in order to reduce the risk of bleeding (11). Infections of the maternal reproductive system can be prevented by maintaining high level of hygiene and early signs of infections should be identified and treated promptly. Pre-eclampsia should be tested in the pregnant women during maternal care and should be managed on time before they can develop eclampsia. Administration of medications such as magnesium sulfate to the expectant women can reduce the chances of developing eclampsia and pre-eclampsia (12).

In order to prevent maternal deaths through abortion, there should be increased awareness on effective birth control methods to prevent development of unwanted pregnancies (13,14)). In case it is justifiable to perform an abortion due to reasons such as when the pregnancy poses serious risks to the mother, the pregnant women should receive safe and quality abortion and post-abortion health care services according to the existing relevant laws (15). Some of the reasons why pregnant women fail to access quality antenatal and postnatal care are poverty, inaccessibility to health care facilities due to distance and poor transport infrastructure, cultural beliefs regarding pregnancy and childbirth and lack of information about maternal, child and neonatal care (16,17). In efforts to achieve the sustainable development goals, countries worldwide are united to achieve a common goal of reducing maternal mortality significantly by the year 2030 to less than 70 cases per 100,000 births (17,18)). In response to the SDG, the World Health Organization  aims at addressing the inequalities in accessibility to quality newborn and maternal health care (19,20), promoting universal health care coverage and promoting accountability to enhance the quality and equity of health care (21,22). As part of achieving the SDG and MDG goals in regard to enhancing maternal health, the Ethiopian health care sector has invested significant amount of money in creating awareness to its population on the importance of seeking antenatal and postnatal health care services from recognized health care facilities (23).

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